Recognition of the atrioventricular node anatomical structure: Connection between the retroaortic node and the compact node.

INTRODUCTION: The complex electrophysiological phenomena related to the atrioventricular node (AVN) are due to its complex anatomical structures. Aside from the inferior nodal extension (INE), other node-like tissues, such as the retroaortic node (RN), have been described less extensively and may also share the mechanism of normal conduction and abnormal conduction in AVN re-entrant tachycardia. METHODS: High-density sections of the entire AVN were obtained from rats and rabbits. Fibrosis was analyzed by Masson's trichrome staining. Connexin (Cx43, Cx40, and Cx45) and ion channel (Nav 1.5, Cav 3.1, and HCN4) proteins were immunohistochemically labeled for the analysis of tissue features. Three-dimensional (3D) reconstruction of the AV junction was performed to clarify the relationships among different structures. RESULTS: The RN expressed the same connexin isoforms as the compact node (CN) and INE. Nav 1.5 labeling was observed at low levels in the CN, RN, and INE, where Cav 3.1 and HCN4 were expressed. The CN connected with the RN in a narrow strip pattern at the start of the CN. The RN presented as a shuttle shape and was the only tissue directly connected with the atrium in the anterior septum. CONCLUSION: The RN connects with the AVN anatomically, suggesting that direct electrical conduction occurs between them. The entrance of the atria into the AVN is distal to the RN, which may form the fast AVN pathway.

Observation of different tumor motion magnitude within liver and estimate of internal motion margins in postoperative patients with hepatocellular carcinoma.

AIMS: To assess motion magnitude in different parts of the liver through surgical clips in postoperative patients with hepatocellular carcinoma and to examine the correlation between the clip and diaphragm motion. METHODS: Four-dimensional computed tomography images from 30 liver cancer patients under thermoplastic mask immobilization were selected for this study. Three to seven surgical clips were placed in the resection cavity of each patient. The liver volume on computed tomography image was divided into the right upper (RU), right middle (RM), right lower (RL), hilar, and left lobes. Agreement between the clip and diaphragm motion was assessed by calculating intraclass correlation coefficient, and Bland-Altman analysis (Diff). Furthermore, population-based and patient-specific margins for internal motion were evaluated. RESULTS: The clips located in the RU lobe showed the largest motion, (7.5±1.6) mm, which was significantly more than in the RM lobe (5.7±2.8 mm, p=0.019), RL lobe (4.8±3.3 mm, p=0.017), and hilar lobe (4.7±2.7 mm, p<0.001) in the cranial-caudal direction. The mean intraclass correlation coefficient values between the clip and diaphragm motion were 0.915, 0.735, 0.678, 0.670, and the mean Diff values between them were 0.1±0.8 mm, 2.3±1.4 mm, 3.1±2.0 mm, 2.4±1.5 mm, when clips were located in the RU lobe, RM lobe, RL lobe, and hilar lobe, respectively. The clip and diaphragm motions had high concordance when clips were located in the RU lobe. Internal margin can be reduced from 5 mm in the cranial-caudal direction based on patient population average and to 3 mm based on patient-specific margins. CONCLUSIONS: The motion magnitude of clips varied significantly depending on their location within the liver. The diaphragm was a more appropriate surrogate for tumor located in the RU lobe than for other lobes.